Complaint·April 28, 2025

Report Continued from LIC 9099... It was alleged that staff did not meet resident’s oxygen needs. It was reported that Resident #1 (R1) was observed with low oxygen levels, and R1’s oxygen machine was used to restore their oxygen levels to normal. However, facility staff were instructed to turn off the oxygen machine to conserve electricity. Records reviewed and interviews conducted revealed that R1 was admitted to hospice care on 05/20/2023, with a primary diagnosis of Alzheimer’s disease and secondary diagnoses of hypertension and depression. According to the hospice care plan dated 05/20/2023, the doctor’s orders included the use of a nebulizer and oxygen concentrator at 5L as needed for shortness of breath or wheezing. Interviews further revealed that R1’s oxygen and pulse levels are frequently monitored throughout the day. If the oximeter indicates that R1’s oxygen levels fall below 90%, staff are instructed to turn on R1’s oxygen machine. However, if the oximeter reads 100%, the oxygen machine is turned off to maintain R1’s safety. Additionally, all four staff members interviewed denied turning off R1’s oxygen when needed or advising another staff member to turn off the oxygen while in use. Furthermore, during an interview with a resident, resident denied being refused assistance or medications by facility staff, stating they had no concerns and were receiving great care. Based on the information obtained and reviewed during the course of the investigation, the Department has insufficient evidence to support the allegation of “staff did not meet resident’s oxygen needs”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and copy issued.